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Men's Health History Form
Personal Information    
Name:   Age:
Address:   Height:
E-mail:   Birthdate:
How often do you check mail:   Place of birth:
Home Phone:   Current weight:
Work Phone:   Weight six months ago:
Cell Phone:   One year ago:
    Would you like your weight to be different:
    If so, what?:
Social Information    
Relationship status?:   Children?:
Pets?:   Occupation?:
Hours of work per week:    
Health Information    
Please list your main health concerns:   What blood type are you?:
Other concerns and/or goals?:   Do you sleep well?:
At what point in your life did you feel best:   Do you wake up at night?:
Any serious illness/hospitalizations/injuries:   Why?:
How is/was the health of your mother?:   Any pain, stiffness or swelling?:
How is/was the health of your father?:   Constipation/Diarrhea/Gas?:
What is your ancestry?:   Allergies or sensitivities? Please explain:
Medical Information    
Do you take any supplements or medications:   Any healers, helpers, pets or therapies with which you are involved?:
Please List:   Please List:
    What role do sports and exercise play in your life?:
Food Information:    
What foods did you eat often as a child?   What’s your food like these days?
Breakfast   Breakfast
Lunch   Lunch
Dinner   Dinner
Snacks   Snacks
Liquids   Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:
Do you cook?:    
What percentage of your food is home cooked?:    
What percentage is not?:    
Where do you get the rest?:    
Do you crave sugar, coffee, cigarettes, or have any major addictions?:
The most important thing I should change about my diet to improve my health is:
Aditional Comments    
Anything else you would like to share?: